Failure to Implement Infection Control Measures for COVID-19 Exposure
Penalty
Summary
The facility failed to minimize the risk of spreading infection by not implementing appropriate infection prevention and control measures for a resident exposed to COVID-19. Observation revealed that a resident who shared a room with another resident in isolation for COVID-19 was not provided with or observed using personal protective equipment (PPE) such as masks, gowns, or gloves. There were no isolation signs or PPE supplies at the entrance to the room, and no barriers were present between the two residents. The resident, who was severely cognitively impaired and required supervision for decision-making, was seen leaving the room and walking through common areas without a mask. Staff did not intervene or encourage the resident to wear a mask or return to their room, and staff themselves were not observed wearing isolation masks in the hallway. Record review indicated that the resident had a history of removing isolation signage and PPE supplies from their room, and staff were aware of this behavior. The resident had tested negative for COVID-19 but chose to remain in the room with the COVID-19 positive roommate. Despite being informed of the need to wear a mask when leaving the room, the resident was allowed to move freely throughout the facility without adherence to infection control protocols, and staff did not enforce or support these measures.